A Cross-Sectional Study of Complications and Management of Varicose Veins at SVRRGGH, Tirupati

BACKGROUND Chronic venous disorders are an important cause of disease and disability worldwide. Varicose veins are dilated, tortuous elongated veins. Varicose veins are either primary or secondary. Most of the patients are asymptomatic. Indian populations present with complications like venous bleed, thrombophlebitis, chronic venous insufficiency leading to edema, eczema, lipodermatosclerosis, and venous ulcers. Varicose vein surgery is characterized by a high recurrence rate of 20 % to 60 % after 5 years and even higher after longer periods of observation. Recurrence may be due to several causes like inaccurate initial diagnosis, progression of disease, inadequate initial surgery, altered venous dynamics, and neovascularisation. METHODS In this cross sectional single center study, 100 patients above 18 years of of age of both genders presenting with complications of varicose veins and cases of postoperative recurrent varicose veins were included. This study was conducted in the Department of General Surgery, Sri Venkateswara Ramnarayan Ruia Government General Hospital (SVRRGGH), Tirupati, over a period of one year. RESULTS In the present study, the great saphenous vein (GSV) was involved in 85 % of cases, the short saphenous vein (SSV) in 2 %, and both long and short saphenous in 9 %. The commonest complication was edema in 88 % of the patients, followed by 43 % with eczema. Recurrent varicose veins were seen in 4 % of patients. CONCLUSIONS Complications were more common in our setting at the time of presentation. Variable anatomy of the venous system of the lower limb makes prior duplex scan assessment compulsory in the surgical management of cases. Surgical management is to be planned properly after complete evaluation and should be planned at the right time, as it is a progressing clinical entity. KEYWORDS Varicose Veins, Complications, Recurrence, Management

Cellular senescence at the saphenofemoral junction in patients with healthy, primary varicose and recurrent varicose veins – A pilot study

Objectives Cellular senescence could play a role in the development of venous disease. Superficial venous reflux at the saphenofemoral junction is a common finding in patients with primary varicose veins. Furthermore, reflux in this essential area is associated with higher clinical stages of the disease and recurrent varicose veins. Therefore, this pilot study aimed to investigate cellular senescence in the immediate area of the saphenofemoral junction in patients with healthy veins, primary varicose veins and additionally in patients with recurrent varicose veins due to a left venous stump. Methods We analyzed vein specimens of the great saphenous vein immediately at the saphenofemoral junction. Healthy veins were collected from patients who underwent arterial bypass reconstructions. Samples with superficial venous reflux derived from patients who received high ligation and stripping or redo-surgery at the groin, respectively. Sections were stained for p53, p21, and p16 as markers for cellular senescence and Ki67 as a proliferation marker. Results A total of 30 samples were examined (10 healthy, 10 primary varicose, and 10 recurrent varicose veins). We detected 2.10% p53+ nuclei in the healthy vein group, 3.12% in the primary varicose vein group and 1.53% in the recurrent varicose vein group, respectively. These differences were statistically significant ( p = 0.021). In the healthy vein group, we found 0.43% p16+ nuclei. In the primary varicose vein group, we found 0.34% p16+ nuclei, and in the recurrent varicose vein group, we found 0.74% p16+ nuclei. At the p < 0.05 level, the three groups tended to be significant without reaching statistical significance ( p = 0.085). There was no difference in respect of p21 and Ki67. Conclusion We found significantly higher expression rates of p53 in primary varicose veins at the saphenofemoral junction than in healthy veins. p16 expression tended to be increased in the recurrent varicose vein group. These preliminary findings indicate that cellular senescence may have an impact in the development of varicose veins or recurrence. Further studies addressing this issue are necessary.

A case of recurrent varicose veins due to the multiple fistulas from superficial femoral artery

Recurrent varicose veins are considered to be caused by the recurrence of reflux but rarely may be secondary to other pathologies. A 39-year-old man complained of right lower leg skin pigmentation, pain and fatigue for several years. Duplex ultrasound revealed that the great saphenous vein diameter at the saphenofemoral junction level was 7.7 cm, and at the knee medial level was 14.4 cm. The reflux time at the proximal great saphenousvein level was 1.85 s. Endovenous laser ablation for dilated and refluxed great saphenous vein was performed. However, 1 year later, the symptoms recurred. Duplex ultrasound suspected abnormal arterial flow from the right superficial femoral artery to the recanalized segment of previously ablated great saphenous vein and anterior accessory saphenous vein. One month later, despite the successful re-endovenous laser ablation, the symptoms recurred. Computed tomography angiography showed three fistulous vessels from superficial femoral artery to anterior accessory saphenous vein. Combined treatments with endovenous laser ablation and coil embolization was performed. Ultimately, the fistulas were obliterated and the patient remained free of symptoms. Varicose veins due to the fistulas from superficial femoral artery are rare and difficult to diagnose but can be entirely treated with the percutaneous approach.

Evidence of Foam Sclerotherapy in the Treatment of Recurrent Varicose Veins

Purpose Efficacy and safety of ultrasound-guided foam sclerotherapy (UGFS) for the treatment of primary venous disease is proven, but the main application field of UGFS remains the treatment of recurrent varicose veins (RVV). The aim of this study is to determine the extent to which this treatment indication is evidence-based. Methods In PubMed and other publicly accessible databases, literature was reviewed until June 2018 and checked for relevance. The focus was on results with regard to anatomical success as well as clinical success and perception by patients. Results Several observational studies comprised a subgroup of RVV patients, but systematic stratification for RVV patients were only rarely performed. In most of these studies including the few reports specifically investigating RVV patients anatomical success as the primary outcome measure revealed similar results compared to primary interventions and favourable results in patients with neovascularization. Data on clinical outcome and patient perception were inconclusive due to low study numbers and insufficient stratification. Complications in RVV patients were rare. Conclusion Although the advantages inherent to the UGFS principle provide a strong rationale that this method best meets the requirements of the specific RVV characteristics, concept and previous observations should be supported by more evidence. Systematic studies in RVV patients with sufficient sample size are required.